Clinical psychologists: Along with the growth of PhD programs has been the development of programs that are called “professional schools” of psychology some of which offer a PhD and some of which offer a newer degree, the doctor of psychology (PsyD). Some psychologists are trained within the field of counseling psychology , where the emphasis is on normal adjustment and development, rather than on the psychological disorders. Clinical psychologists are trained in conducting psychological testing , a broad range of measurement techniques, all of which involve having people provide scorable information about their psychological functioning. Psychiatrists: Medical doctors (MDs) with advanced training in treating people with psychological disorders.
In making a diagnosis, mental health professionals use the standard terms and definitions contained in the Diagnostic and Statistical Manual of Mental Disorders (DSM) . A syndrome is a collection of symptoms that form a definable pattern.
The authors of the DSM-IV had to ensure that the diagnoses would meet the criteria of reliability , meaning that a given diagnosis will be consistently applied to anyone showing a particular set of symptoms. Teams of researchers throughout the United States have continued to investigate the validity of the classification system, meaning that the diagnoses represent real and distinct clinical phenomenon. In all of these efforts, experts have had to keep in mind the base rate of a disorder, the frequency with which it occurs in the general population. The lower the base rate of a disorder, the more difficult it is to establish the reliability of the diagnosis because there are so few cases to compare. Social Context: Does DSM-IV unfairly label people? Some behavior that seems disordered may be appropriate at least understandable when one considers the context in which it occurs.
The first edition of the American Psychiatric Association’s DSM was the first official psychiatric manual to describe psychological disorders and was a major step forward in the search for a standard set of diagnostic criteria. However, criteria were vague, had poor reliability, and were based on faulty assumptions about origins of disorders. The second edition, DSM-II , based its classification of mental disorders on the system contained in the International Classification of Diseases (ICD) . DSM-III provided precise criteria and definitions for each disorder, enabling clinicians to be more quantitative and objective. To specify criteria further, DSM-III-R was published as an interim manual until a more complete overhaul.
The DSM-IV relied on comprehensive reviews, thorough analyses of research data, and field trials to test reliability and validity further. A “text revision,” the DSM-IV-TR , included editorial revisions to the DSM-IV. Many professionals simply refer to it as the DSM-IV.
A syndrome is a collection of symptoms that forms a definable pattern. Mental disorder: A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an acceptable and culturally sanctioned response to a particular event, for example, the death of a loved one.
One of the most prominent assumptions of the DSM-IV is that this classification system is based on a medical model orientation, in which disorders, whether physical or psychological, are viewed as diseases. Atheoretical orientation: The DSM-IV simply classifies and describes a set of symptoms for each disorder without regard for explaining their cause, without theoretical orientation. Categorical approach: Implicit in the medical model is the assumption that diseases fit into distinct categories. Multiaxial system: Each axis is a class of information regarding an aspect of an individual’s functioning.
The major clinical disorders and adjustment disorders are on Axis I. Axis II disorders (personality disorders and mental retardation) represent enduring characteristics of an individual’s personality or abilities. Personality disorders: Personality traits that are inflexible and maladaptive and that cause either subjective distress or considerable impairment in a person’s ability to carry out the tasks of daily living. On Axis III , the diagnostician notes the individual’s medical conditions, which may or may not be connected to the person’s psychological condition. On Axis IV , the clinician documents events or pressures that may affect the diagnosis, treatment, or outcome of a client’s psychological disorder. Axis V is used to document the clinician’s overall judgment of a client’s psychological, social, and occupational functioning. The rating of the client’s functioning during the preceding year provides the clinician with important information about the client’s prognosis , or likelihood of recovering from the disorder.
When clinicians use multiple diagnoses, they typically consider one of the diagnoses to be the principal diagnosis , the disorder that is considered to be the primary reason the individual is seeking professional help. In certain cultures, psychological disorders may be expressed as particular patterns of behavior, perhaps reflecting predominant cultural themes that date back for centuries, known as culture-bound syndromes . For example, “ghost sickness” is a preoccupation with death and the deceased that is reported by members of American Indian tribes.
When clinicians use multiple diagnoses (e.g., alcoholism and depression in the same person), they typically consider one of the diagnoses to be the principle diagnosis , the primary reason the individual is seeking professional help.
The first phase of treatment planning is to establish treatment goals, objectives the clinician hopes to accomplish in working with the client. These goals range from the immediate to the long term. First, the clinician deals with the crisis at hand, then handles problems in the near future, and finally addresses issues that require extensive work well into the future. However, in other cases, there may be a cyclical unfolding of stages.
Treatment sites include psychiatric hospitals, outpatient treatment settings, halfway houses and day treatment centers, and other treatment sites such as the school or workplace, that provide mental health services. The more serious the client’s disturbance, the more controlled the environment that is needed and the more intense the services. Hospitalization is also recommended for clients who have disorders that require medical interventions and intensive forms of psychotherapeutic interventions. Because hospitalization is such a radical and expensive intervention, most clients receive outpatient treatment in which they are treated in a private professional office or clinic. Community mental health centers (CMHCs) are outpatient clinics that provide psychological services on a sliding fee scale for individuals who live within a certain geographic area. Halfway houses are designed for clients who have been discharged from psychiatric facilities but who are not yet ready for independent living. Day treatment programs are designed for formerly hospitalized clients as well as clients who do not need hospitalization but do need a structured program during the day, similar to that provided by a hospital. Psychological treatment is also provided in settings not traditionally associated with the provision of mental health services such as the schools and workplace.
The modality , or form in which psychotherapy is offered, is another crucial component of the treatment plan. In individual psychotherapy , the therapist works with the client on a one-to-one basis. In family therapy ; several or all of the family members are involved in the treatment. Group therapy provides a modality in which troubled people can openly share their problems with others, receive feedback, develop trust, and improve interpersonal skills. Milieu therapy , is based on the premise that the milieu, or environment, is a major component of the treatment; a new setting, in which a team of professionals works with the client to improve his or her mental health, is considered to be better than the client’s home and work environments. Whatever modality of treatment a clinician recommends, it must be based on the choice of the most appropriate theoretical perspective or the most appropriate aspects of several different perspectives.
In other words, clinicians should base treatments on state-of-the-art research findings which they adapt to the particular features of each client.
In optimal situations, psychotherapy is a joint enterprise in which the client plays an active role. It is largely up to the client to describe and identify the nature of his or her disorder, to describe personal reactions as the treatment progresses, and to initiate and follow through on whatever changes are going to be made. Some obstacles that clinicians face in their efforts to help clients include curious and frustrating realities. The most frustrating involve the client who is unwilling to change.
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